DISORDERS OF THE LACRIMAL SYSTEM

Dr Russell J Watkins

Lacrimal System Disorders Tear film disorders (all phases)

The dry eye The wet eye

Drainage obstruction Lacrimal gland inflammation Lacrimal gland tumours Lacrimal sac tumours

Keratoconjunctivitis Sicca Aqueous phase deficiency Symptoms

Redness Burning sensation Gritty sensation “Stiff lids” - difficulty with initial opening 2° epiphora in some cases

Keratoconjunctivitis Sicca Signs

Tear meniscus TF debris; TBUT Corneal epithelial filaments SPE; frank ulceration Vital staining with rose Bengal 1% Abnormal Schirmer’s test (type I & type 2)

Keratoconjunctivitis Sicca Other investigations

Reduced lysozyme activity in Sjögren’s syndrome

Tear osmolarity (normal = ~300mosmol/l; Aqueous deficiency = ~340mosmol/l)

Keratoconjunctivitis Sicca Causes of aqueous deficiency

Idiopathic/age related 1° & 2° Sjögren’s syndrome Inflammatory or infiltrative lesions e.g. Lymphoma, TB,

sarcoidosis Congenital/iatrogenic absence of lacrimal gland CN V defect (sensory arc) CN VII defect (motor arc; anticholinergics) ADRs (antihistamines; -blockers; phenothiazines; OCP)

Mucin Deficiency Signs

TBUT Bitot’s spots: interpalpebral conjunctival

foamy patches associated with severe vitamin A & xerophthalmia

Causes Vitamin A deficiency Cicatrising disease (loss of conjunctival goblet

cells): trachoma, SJS, cicatricial pemphigoid, chemical burns

Oily Layer Abnormalities Meibomianitis, MGD Blepharitis, often staphylococcal & compounding

aqueous deficiency

Management of Dry Eyes

Artificial tears - if used very frequently, consider preservative free preparations

Lid toilet and compresses with occasional use of topical antibiotics

Mucolytics for filamentary keratitis Vitamin A supplements in xerophthalmia

(topically is experimental) Punctal plugs - optometric role? Stop exacerbating medication Surgery to lid deformities/punctal occlusion

Epiphora Causes

Exclude eye disease• Allergic/infective/irritative conjunctivitis• Trichiasis, distichiasis• Corneal disease

Dry eye with compensatory hypersecretion Lacrimal pump failure (e.g. CN VII palsy) Lid-globe incongruity such as ectropion Lacrimal drainage system obstruction Hypersecretion

Epiphora Assessment of the patient with epiphora

Exclude dry eye Check punctal position & patency Apply lacrimal sac pressure looking for reflux

(mucocele) Test lacrimal drainage patency

Epiphora Specific tests of patency

Fluorescein disappearance test Jones’ test - staining of nasal swab after

instillation of fluorescein into fornix Syringing & probing - diagnostic & therapeutic

(optometric role?) Ophthalmologists may also perform CT & MRI

scans, radionucleotide scans

Lacrimal Drainage System Obstruction

Causes: Congenital

• Absence/atresia of the canaliculi &/or puncta

• Incomplete opening of the nasolacrimal duct

• Associated with craniofacial anomalies Senile: punctal stenosis or associated with

chronic infection Ectropion or conjunctival cicatrisation

Lacrimal Drainage System Obstruction

Causes (continued) Trauma (physical or radiation) Inflammation (sarcoid, Wegener’s) Drug induced (pilocarpine, idoxuridine,

adrenaline et al) Infection

• Acute or chronic dacryocystitis• Canaliculitis (HSV, VZV, actinomyces

israelii)• Sinusitis

Lacrimal Drainage System Obstruction

Causes (continued) Lacrimal sac tumours

• 1° (e.g. papillomata, SCC)• 2° (e.g. BCC, lymphomata, sinus tumours)

Lacrimal Drainage System Obstruction

Treatment depends on site of obstruction & falls into the ophthalmologists realm Puncta may be dilated (± snips) Lid malposition correction Recanalisation operations Treat infectious causes (e.g. canaliculitis,

dacryocystitis) Recurrent dacryocystitis requires DCR Probing atretic nasolacrimal ducts, DCR =

mainstay of treatment of NLD obstruction

Lacrimal Gland Inflammation Viral dacroadenitis e.g mumps, glandular fever Acute bacterial dacryoadenitis often 2° to

conjunctivitis Chronic bacterial e.g. TB, syphilis Inflammatory conditions e.g. Sjögren’s,

sarcoidosis, Wegener’s Reactive lymphoid hyperplasia, lymphoma

Lacrimal Gland Tumours 50% are inflammations & lymphoid proliferations Pleomorphic adenoma (benign mixed cell

tumour) Epithelial origin 20-60 yrs Painless, usually with long history (>1yr) Palpable hard nodular mass Non-axial proptosis; ROEM; astigmatism Surgical removal en bloc rather than biopsy Good prognosis if completely removed

Lacrimal Gland Tumours Carcinoma

Epithelial origin Painful, usually short history Causes local bony erosion Usually biopsied after trial of antibiotics If biopsy +ve, requires radical local resection

with RT Poor prognosis

Lacrimal Sac Tumours Features

Rare Painless swelling Punctal reflux of pus & blood Can be SCC, adenocarcinoma

DISORDERS OF THE SCLERA & EPISCLERA

Dr Russell J Watkins

Episcleritis Inflammation of episclera & overlying

conjunctiva, occasionally associated with systemic disease (HZO, RA)

Nodular or diffuse Benign & self-limiting More common in young adults, M=F Mild ache, tenderness, burning Blanches with phenylephrine

Episcleritis Treatment

None (self-limiting) Topical corticosteroids Systemic/topical NSAIDs

Scleritis Less common but more serious than episcleritis Can be very painful; occasionally painless Pain can be worse at night Older age group; F>M

Scleritis Systemic disease associated with scleritis

HZO RA SLE PAN Wegener’s granulomatosis Behçet’s syndrome Ankylosing spondylitis IBD et al

Scleritis Classified as

Anterior scleritis Posterior scleritis

Anterior scleritis further subclassified Diffuse non-necrotizing Nodular non-necrotizing Necrotizing, without inflammation Necrotizing with inflammation

Anterior Scleritis Diffuse non-necrotizing

Segmented or widespread inflammation Oedema Treat with oral NSAIDs e.g. flurbiprofen

Nodular non-necrotizing Focal inflammation & oedema Nodule is immobile Treat with oral NSAIDs e.g. indomethacin

Anterior Scleritis Necrotizing, without inflammation

Scleromalacia perforans Seen in RA Painless scleral thinning with marked

ischaemia Perforation rare Treatment is difficult

Anterior Scleritis Necrotizing, with inflammation

Progressive, painful Injected ++ Scleral ischaemia & non-perfusion Focal or diffuse Associated anterior uveitis Scleral thinning

Anterior Scleritis Necrotizing, with inflammation (cont.)

25% 5-yr mortality from associated disease Severe complications e.G. Peripheral corneal

melt, cataract, glaucoma Treat with high dose systemic steroids

±immunosuppressants

Posterior Scleritis Features

Diffuse or focal thickened inflamed posterior sclera ±pain

Anterior segment may be unaffected Easily missed Exudative RD; choroidal folds Posterior vitritis; disc & macular oedema Uveal effusion syndrome Proptosis Ocular myositis with ophthalmoplegia Usually no associated systemic disorder

Posterior Scleritis Investigations

CT scan or USS(B) Treatment

High dose systemic steroids ±immunosuppression